Grief After Suicide

Understanding the Consequences and Caring for the Survivors

John R. Jordan, John L. McIntosh, John R. Jordan, John L. McIntosh

• Editorial: Routledge
• Año: 2011
• ISBN:
  9781135849252
• Edición: 1
• Categoría: Psicologia
• Categoría: Consulenza psicoterapeutica

here are over 38, 000 suicide deaths each year in the United States alone, and the numbers in other countries suggest that suicide is a major public health problem around the world. Asuicide leaves behind more victims than just the individual, as family, friends, co-workers, and the community can be impacted in many different and unique ways following a suicide. And yet there are very few professional resources that provide the necessary background, research, and tools to effectively work with the survivors of a suicide.

This edited volumeaddresses the need for an up-to-date, professionally-oriented summary of the clinical and research literature on the impact of suicide bereavement on survivors. It is geared towards mental health professionals, grief counselors, clergy, and others who work with survivors in a professional capacity.Topics covered includethe impact of suicide on survivors, interventions to provide bereavement care for survivors, examples of promising support programs for survivors, and developing a research, clinical, and programmatic agenda for survivors over the next 5 years and beyond.

SECTION 1
The Impact of Suicide

CHAPTER 1
Suicide Bereavement: Why Study Survivors of Suicide Loss?

John R. Jordan and John L. McIntosh

The personal narratives of many suicide survivors testify to the reality that the death of a loved one to suicide can be an enormously difficult experience, one that may have life-transforming effects on the mourner (Alexander, 1991; Jackson, 2004; Stimming & Stimming, 1999; Wrobleski, 2002). Empirical and clinical study of survivors also offers considerable support for this intuitive understanding that the loss of a loved one to suicide may be a particularly difficult form of bereavement (de Groot, De Keijser, & Neeleman, 2006; Jordan, 2001, 2008, 2009; Knieper, 1999). Nonetheless, the question of whether mourning after suicide is different—and, if so, whether the differences are quantitative or qualitative in nature (or both)—remains a challenge to be resolved (McIntosh, 2003). The answers to these questions have important implications for how we think about the impact of suicide on survivors and how we develop support services that might ameliorate some of the suffering of those left behind (Jordan, 2001; McIntosh, 2003). Beyond that, there are important definitional issues about survivorship that suicidology and thanatology have yet to address satisfactorily. These issues include determining (a) who is considered a survivor, (b) how many survivors there are, and (c) what the relationship is between exposure to suicide and the experience of becoming a survivor. Our goals for this opening chapter are twofold: to offer a framework for addressing questions (a) and (b) and to make the case for why specialized study of suicide bereavement is needed. In Chapter 2, we address the debate within the literature about whether bereavement after suicide may differ from bereavement after other modes of death—and, if so, in what ways. We also offer a conceptual framework for thinking about the differences and commonalities in bereavement after suicide and after other types of losses. In Chapters 3 through 5, we provide comprehensive reviews of the literature that address the actual impact of suicide on adults, children, and families, and on clinicians who work with suicidal patients.

The Definition of Suicide Survivorship

Who Is a Survivor?

The question of what constitutes survivorship is both conceptual and empirical. Perhaps surprisingly, the conceptual specification of who is a suicide survivor has never really been addressed, let alone agreed upon by writers in the field (Andriessen, 2009; Cerel, Padgett, Conwell, & Reed, 2009; McIntosh, 2003).¹ Most survivor research studies simply define exposure to a suicide as the criteria for participation, and/or they study the immediate kin of the deceased—or, in the case of adolescents, the close friends of the deceased. Nonetheless, we believe that these definitions are, respectively, too broad or too narrow to denote who should be regarded as a potential suicide survivor. The reality is that we simply do not know how many people in a social network are negatively affected by a given suicide because the literature has made two simplistic assumptions: (a) that all suicides are more or less the same in their impact and (b) that the degree of impact is largely a function of the degree of kinship closeness to the deceased. We believe that the time has come to develop a more inclusive and empirically based foundation for defining survivorship.

For example, consider the hypothetical suicide of a middle-aged man, a Mr. Smith. He is deeply involved in his small-town community as a son, husband, father, brother, professional person, volunteer soccer coach for his children’s teams, deacon in his church, and longtime resident of his town. Although it is obvious that Mr. Smith’s wife and children are likely considered survivors, there are many others in his social network who might also be significantly and quite negatively affected by his death. To name but a few, there are his parents, siblings, and extended family members; his colleagues and clients at work; his neighbors; the children and parents of the teams he has coached; his fellow church members; and his current friends not only from the town but from earlier in his life (e.g., a college roommate or a former girlfriend). Although not all of these people will necessarily be significantly affected by Mr. Smith’s death, it seems plausible that any one of them might, in fact, be a candidate for a problematic bereavement experience after his suicide.

Contrast Mr. Smith’s death with the suicide death of a Mr. Jones. He is an elderly homeless man who has suffered from mental illness most of his adult life. He has been reclusive for many years, having only sporadic contact with a small number of other homeless people and with social agency workers. He has only one living sister, with whom he has not had contact for many years. It seems plausible, in the case of Mr. Jones’s death, that there are far fewer people for whom his death will deal a severe and lasting psychological blow.

Defining Survivorship

As shown in the two examples offered previously, survivorship might be defined by at least three dimensions. The previously mentioned and most common one is kinship proximity—and, certainly, the family members of either Mr. Smith or Mr. Jones are at risk for having a difficult response to these deaths. Empirical evidence supports the idea that kinship proximity is directly related to the severity of impact of a suicide (Cleiren, Diekstra, Kerkhof, & van der Wal, 1994; Mitchell, Kim, Prigerson, & Mortimer-Stephens, 2004). However, if Mr. Jones’s sister has not had contact with him for many years and is dealing with her own medical or financial problems, she may actually have very little response to her brother’s death, despite the closeness of her formal kinship relationship with Mr. Jones. Thus, kinship proximity may not always be a marker of survivorship.

A second and more inclusive criterion for survivorship would be those people who have (or have had) a close psychological association with or attachment to the deceased, regardless of their kinship status. The circle of potential survivors grows larger when this definition is used. For Mr. Smith, a larger circle of individuals—for example, his close friends, the children whom he has coached, and a former college roommate with whom he had been very close—might all experience high levels of grief and distress at his passing. Even for Mr. Jones, the circle of potential survivors might be larger than first assumed. For example, an agency social worker who has known and worked with him periodically for many years might find herself feeling surprisingly sad and guilty after her client’s suicide. The impact of suicide on professionals who may have worked with the deceased, and the potential for these professionals to also become survivors, has been largely ignored in the mental health field (Campbell, 2006; see Chapter 5 for more information on this topic). A definition of survivorship that includes those who are more closely psychologically involved with the deceased has also received empirical support as an important predictor of grief intensity and distress (Brent, Perper, Moritz, Liotus, et al., 1993; Mitchell et al., 2004; Reed, 1993; Reed & Greenwald, 1991; J. Zhang, Tong, & Zhou, 2005).

A third definition of survivorship would include those who are greatly distressed after the suicide, regardless of their kinship relationship with or psychological closeness to the deceased. For example, the parent of one of the children coached by Mr. Smith who has known him only casually might feel quite angry with Mr. Smith’s “betrayal” of the children through the suicide and the bad role model that this parent believes has been set for them. Another example is a homeless person who has never met Mr. Jones but who has been depressed and struggling with his own suicidal feelings—he may hear the news of the suicide on the street and decide to take his own life. Yet another example is someone who feels psychologically responsible for causing, or failing to prevent, the suicide—for example, the engineer of a subway train that strikes and kills a young person who had jumped into the train’s path may experience haunting guilt and trauma symptoms after the death, regardless of his obvious innocence in the death.

A General Definition of Survivorship

We draw on all three of these criteria to propose a more precise answer to the question “Who is a survivor?”

A suicide survivor is someone who experiences a high level of self-perceived psychological, physical, and/or social distress for a considerable length of time after exposure to the suicide of another person.

Note that embedded in this definition is an important distinction between exposure to a suicide and survivorship. Thus, only a subset of people who are exposed to a suicide will go on to become survivors. The obvious questions of what constitutes a “high” level of distress and a “considerable” length of time are important and, ultimately, empirical questions that can be answered by good research to establish the normative distribution of distress in social networks affected by suicides. The recent effort in thanatology to create a new diagnostic category called complicated grief (CG)—more recently referred to as prolonged grief disorder (PGD; Lichtenthal, Cruess, & Prigerson, 2004; Prigerson et al., 2009; Prigerson & Maciejewski, 2005)—is one possible (but certainly not the only) starting point for this endeavor. For example, people who meet symptom criteria for this new disorder after a suicide could be operationally considered survivors for research purposes. Note also that in our proposed definition, the distress can be self-perceived (e.g., the person reports feeling very guilty), observed by others (e.g., the person acts in very angry ways), or identified by more formal measurement (e.g., grief or depression symptom measures). However, we believe that a key element of the definition of survivorship must include self-definition, regardless of any attempts to “objectively” define this term. Survivorship frequently carries with it a number of negative (and perhaps some positive) consequences that transcend simple grief or psychiatric symptoms to include longer term changes in self-identity and life narrative as a result of the death (Feigelman, Jordan, & Gorman, 2009; Stimming & Stimming, 1999; see Chapter 11 for more discussion of the impact of suicide on meaning making and post-traumatic growth processes in survivors). Thus, we would be hard put to define as a survivor someone who did not personally feel that his or her life had been significantly affected by the death.

The time criterion for survivorship is more difficult to define because, in our experience, many people in the deceased person’s social network are initially upset and grieving after a suicide but will not necessarily show a lasting negative impact. Although the 6-month duration requirement for the PGD diagnosis is one possible criterion, our personal experience with survivors suggests that this may be too short a time period and is, therefore, likely to produce too many “false positives.” A 1-year duration criterion might better describe those who are significantly affected and who are likely to have lasting effects from the suicide. Again, this...